A nurse is reviewing the reported medications of a client wh...

A nurse is reviewing the reported medications of a client who was recently admitted. The medications include cimetidine (Tagamet) and imipramine hydrochloride (Tofranil). Knowing that cimetidine decreases the metabolism of imipramine hydrochloride, the nurse should identify that this combination is likely to result in which of the following effects?

A. Decreased therapeutic effects of cimetidine
B. Increased risk of imipramine hydrochloride toxicity
C. Decreased risk of adverse effects of cimetidine
D. Increased therapeutic effects of imipramine hydrochloride

Correct Answer: B

Rationale: The correct answer is B: Increased risk of imipramine hydrochloride toxicity. Cimetidine inhibits the metabolism of imipramine hydrochloride, leading to increased levels of imipramine in the body. This can result in a higher concentration of imipramine, potentially causing toxicity. This interaction is known as a pharmacokinetic drug-drug interaction.
Incorrect choices:
A: Decreased therapeutic effects of cimetidine - This is incorrect because cimetidine's therapeutic effects are not directly impacted by its interaction with imipramine.
C: Decreased risk of adverse effects of cimetidine - This is incorrect as there is no evidence to suggest that the interaction with imipramine decreases the risk of adverse effects of cimetidine.
D: Increased therapeutic effects of imipramine hydrochloride - This is incorrect as the increased risk of toxicity does not equate to increased therapeutic effects.

A nurse is preparing to insert an NG tube for a client who requires gastric decompression. Which of the following actions should the nurse perform prior to beginning the procedure? Select all.

A. Review a signal the client can use if feeling any distress.
B. Lay a towel across the client's chest.
C. Administer oral pain meds.
D. Obtain a Dobhoff tube for insertion.
E. Have a petroleum-based lubricant available.

Correct Answer: A, B

Rationale: Correct Answer: A, B

Rationale:
A: Review a signal the client can use if feeling any distress - This is important to ensure the client can communicate any discomfort or issues during the procedure.
B: Lay a towel across the client's chest - Helps protect the client's clothing and bedding from potential spillage during the procedure.
C: Administer oral pain meds - Not necessary prior to NG tube insertion for gastric decompression.
D: Obtain a Dobhoff tube for insertion - Dobhoff tube is not typically used for gastric decompression with NG tube.
E: Have a petroleum-based lubricant available - Lubricant is required for NG tube insertion but not specifically petroleum-based.
F:
G:
Summary: Choices C, D, and E are not necessary prior to beginning the NG tube insertion procedure. Choice A and B are essential steps to ensure patient safety and comfort during the process.

A nursing instructor is reviewing the wound healing process with a group of nursing students. They should be able to identify which of the following alterations as a wound or injury that heals by secondary intention? Select all.

A. Stage III pressure ulcer
B. Sutured surgical incision
C. Casted bone fracture
D. Laceration sealed with adhesive
E. Open burn area

Correct Answer: A, E

Rationale: The correct answers are A and E because wounds healing by secondary intention involve tissue loss and heal from the bottom up with granulation tissue filling in the wound. A Stage III pressure ulcer and an open burn area are examples of wounds that heal by secondary intention due to tissue loss.
Choices B and D are incorrect because sutured surgical incisions and lacerations sealed with adhesive heal by primary intention, where wound edges are approximated and heal with minimal scarring. Choice C, a casted bone fracture, is incorrect as fractures heal through a different process involving the formation of callus and subsequent bone remodeling, not by secondary intention healing.

A nurse is instructing an AP in caring for a client who has a low platelet count as a result of chemotherapy. Which of the following is the nurse's priority instruction for measuring vital signs for this client?

A. Don't measure the client's temperature rectally.'
B. Count the client's radial pulse for 30 seconds & multiply by 2.'
C. Don't let the client know you are counting her respirations.'
D. Let the client rest for 5 minutes before you measure her BP.'

Correct Answer: A

Rationale: Correct Answer: A: Don't measure the client's temperature rectally.

Rationale: Clients with low platelet count are at risk for bleeding. Rectal temperature measurement poses a risk of mucosal injury and bleeding due to the fragility of the rectal mucosa. Therefore, the nurse's priority instruction is to avoid rectal temperature measurement to prevent any potential harm to the client.

Summary:
B: Counting the radial pulse for 30 seconds and multiplying by 2 is a valid method for measuring heart rate but is not the priority instruction in this case.
C: It is important for the client to be aware that respirations are being counted to ensure accurate measurement. However, this is not the priority instruction for vital sign measurement.
D: Allowing the client to rest for 5 minutes before measuring blood pressure is a good practice, but it is not the priority instruction compared to avoiding rectal temperature measurement for a client with low platelet count.

While a nurse is administering a cleansing enema, the client reports abdominal cramping. Which of the following is the appropriate intervention?

A. Have the client hold his breath briefly
B. Discontinue the fluid instillation
C. Remind the client that cramping is common at this time
D. Lower the enema fluid container

Correct Answer: D

Rationale: The correct answer is D: Lower the enema fluid container. This intervention helps slow down the flow of the enema solution, reducing the client's discomfort from cramping. By lowering the container, the rate of fluid instillation decreases, giving the client's body more time to adjust to the enema. This action promotes better tolerance and helps alleviate abdominal cramping.
Other choices are incorrect:
A: Having the client hold his breath briefly does not address the underlying cause of the cramping and may increase discomfort.
B: Discontinuing the fluid instillation abruptly can cause incomplete cleansing and may not address the cramping effectively.
C: Merely reminding the client that cramping is common does not provide immediate relief or help manage the discomfort.
By choosing option D, the nurse can effectively manage the client's cramping during the enema procedure.

A nurse on a med-surg unit has received change-of-shift report & will care for 4 clients. Which of the following client's needs may the nurse assign to assistive personnel (AP)?

A. Feeding a client who was admitted 24 hrs ago w/aspiration pneumonia
B. Reinforcing teaching w/a client who is learning to walk using a quad cane
C. Reapplying a condom catheter for a client who has urinary incontinence
D. Applying a sterile dressing to a pressure ulcer

Correct Answer: C

Rationale: The correct answer is C because reapplying a condom catheter for a client with urinary incontinence is a task that can be safely delegated to assistive personnel (AP). This task involves a straightforward procedure that does not require advanced nursing skills or critical thinking. The nurse can provide clear instructions and oversee the AP's performance.

Choice A is incorrect because feeding a client with aspiration pneumonia requires close monitoring by a nurse due to the risk of complications. Choice B is incorrect as reinforcing teaching for a client learning to walk with a quad cane involves assessing the client's understanding and progress, which is within the nurse's scope. Choice D is incorrect because applying a sterile dressing to a pressure ulcer requires sterile technique and assessment of wound healing, which should be done by a nurse.